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Blood Donors Registration Form
Please provide the requires Details as all fields are Mandatory. The Information you provide here will be uploaded to our online database and you will receive a email once Registration is done.
 
Personal Details
Donor's Name*
Date of Birth*
Age*  
Gender
Email
Phone
Mobile No*
Contact Details
Address Line 1*
Address Line 2
Address Line 3
District*
 
Pincode*
Preferred Means of Contact
Special Instruction I don't want to disturbed between (DND)
 
At Night
During Official Hours
Mannual Timings
Other Instruction If Any
   
'*'Mandatory Fields
Have You Donated Previously
Yes No  
Your Blood Group
   
Do Your know your Weight?
Do Your know your Haemoglobin Count?
Name of the Blood Bank you want to be associated with (Can Choose Multiple Blood Banks)
Select all that Apply
Have You any reason to believe that you may be
infected by either Hepatitis, Malaria, HIV/AIDS,
and/or Venereal Disease?
Yes No  
In the last 6 Months have you had any history of
the following:
Unexplained Weight Loss  
Repeared Diarrhoea  
Swollen Glands  
Continuous Low-Grade Fever  
In the last 6 Months have you had any:-
Tattooing  
Ear Piercing  
Dental Extraction  
Do you suffer from or have suffered from any of
the following Diseases?
Heart Disease Lung Disease
Kidney Disease Cancer/ Malignant Disease
Epilepsy Diabetes
Tuberculosis Abnormal bleeding tendency
Hepatitis B/C Allergic Disease
Jaundice Saxually Trans. Disease
Malaria Typhoid (Last 1 yr.)
Fainting Spells    
Is There any history of surgery or Blood Transfusion
in the past 6 Months?
Major Surgery Blood Transfusion
Minor Surgery    
Declaration:
  I have read and understood all the information presented above and answered all the questions to the best of my knowledge, and hereby declare that
   
(a) I am ready to donate blood if requested by blood bank/ patients/ patients relatives voluntarily on my own free will, without any expectation of replacement of blood, or any favour in form of cash or kind.
(b) Donation of Blood/ Components is a Medical Procedure and I accept the risk Associated with Blood Donation Procedure.
(c) My Blood or Blood products may be utilized by the blood bank for unknown recipient requiring blood/blood products or may be disposed off as per blood bank norms or Government policy.
(d) I fully understand that voluntary blood donation is a humanitarian service and the persons demanding my blood may be in the state of stress. I hereby declare that under such circumstances I shall patiently handle the situation and keep my cool while contacting me even if during Odd hours/time. In case of unavoidable circumstances I shall write to SBTC, UP to withdraw my offer as voluntary blood donor and to remove my name from voluntary blood donor list on the website without any conflict.
(e) My Blood will be Tested for Hepatitis B, Hepatitis C, Malaria Parasite, HIV and Venereal Diseases in addition to any other screening tests required for ensuring Blood Safety.
(f) All disputes are subject to Lucknow Jurisdiction only.
Security Code  
 
Your Personal Information is Never Sold nor will We Share with Any of There Company or Organization without Prior Consent.